Pediatric issues: Vesicoureteral Reflux and Enuresis Flashcards
What are the 2 sphincters of the bladder? Which is under voluntary control?
Internal and external sphincters - both must RELAX to empty the bladder
EXTERNAL is under voluntary control
What is the major muscle of the bladder?
Detrusor muscle (CONTRACTS to release urine)
The urothelium is…
a) permeable
b) impermeable
b) impermeable
The detrusor muscle is very rich in…
autonomic nervous sytem receptors
How does the SNS affect the bladder?
How does the PSNS affect the bladder?
SNS: Inhibit detrusor muscle contraction + close internal sphincter
PSNS: Contract detrusor muscle + open internal sphincter
Describe the external sphincter
Striated muscle under voluntary control (somatic NS).
Conscious opening (relaxation) or closing (contraction) allows us to control when/where we pee.
Two modes of operation of the bladder?
Storage and elimination (both under control of the central and peripheral nervous systems)
Urination is …
a) voluntary
b) involuntary
a) voluntary
(depends on learned behaviour that develops during maturation of nervous system)
How do infants void?
Infants void via spinal reflex pathways (ANS). Spontaneous detrusor contractions are triggered by bladder distention, while the internal and external sphincters relax.
What enables conscious control of voiding as a child ages?
Voiding reflex pathways come under control of higher cortical centres - detrusor contractions become consciously controlled.
Typically, adult voiding pattern (daytime) is assumed by…
4-5 years of age
Day and night continence is achieved by…
5-7 years of age
When do we start suspecting voiding dysfunction?
In children greater than 5 years of age with symptoms
Common symptoms of voiding dysfunction (11)
- Increased daytime frequency (>8 voids/day)
- Decreased daytime frequency (<3 voids/day)
- Pollakiuria (frequent small voids in previously toilet-trained child)
- Incontinence (uncontrolled leakage)
- Urgency (sudden & unexpected need to void)
- Nocturia (awakening at night to void)
- Hesitancy (difficulty to initiate voiding)
- Straining/Valsalva maneuver (abdominal wall pressure to initiate voiding)
- Weak/intermittent stream
- Holding maneuvers (to postpone/suppress urgency
- Postmicturition dribbling (leakage immediately after voiding)
3 categories of bladder dysfunction in children
neurogenic
anatomic
functional
Define bladder dysfunction (in children)
A condition that affects the ability to urinate normally. Can be caused by a variety of factors (neurogenic, anatomic and functional).
Neurogenic causes of voiding dysfunction (3)
- Spina bifida (congenital anomalies of spinal cord)
- Trauma to CNS or PNS
- Brain or spinal cord tumours
Anatomic causes of voiding dysfunction (4)
- Ectopic ureter bypasses external sphincter and inserts distal to the bladder neck
- Obstruction of bladder outlet (eg. posterior urethral valves in boys)
- Vesico-ureteric reflux
- Polyuria from renal failure
Functional causes (MOST COMMON) (3)
- Maturation delay
- Prolongation of infantile bladder behaviour
- Abnormal acquired toilet training habits
What is spina bifida?
Incomplete closure of the neural tube/spine (spinal cord protrudes out in the lower back)
What is an ectopic ureter and how does it form?
It is a congenital condition where the ureter attaches below the bladder neck (and does not drain urine into the bladder.
Usually, the 2 fetal ureteric buds give rise to two ureters, one of which inserts BELOW the external sphincter
Note: You can also have only 1 ectopic ureter
In a patient with 2 ureters on one side of the GU, which one is more likely to be ectopic?
The upper pole ureter tends to be ectopic
Persistence of urogenital membrane due to presence of posterior urethral valves is only seen in…
boys/males
What are posterior urethral valves?
PUVs are flaps of tissue (persistent urogenital membrane) in the urethra that block urine flow in male infants (congenital anomaly).
What is the treatment of persistence of urogenital membrane?
Surgical treatment (obliteration of membrane)
What is vesico-ureteric reflux?
A congenital defect of the ureterovesical junction (UVJ): urine refluxes from bladder up to the kidneys.
How do we treat a vesico-ureteric reflux? (2)
Antibiotic prophylaxis (to prevent infections) and surgery to correct the UVJ defect.
What are 2 possible surgical treatment options for vesico-ureteric reflux?
What are the 2 possible medical treatment options?
Surgical treatment:
1. Injection of intra-ureteral tissue bulking agents (deflux)
2. Surgical re-implantation of the ureter
Medical treatment:
1. Daily antibiotic prophylaxis
2. Treatment of dysfunctional voiding and chronic constipation
When treating VUR, the daily prophylactic antibiotics should be administered up to age of 2 years for what purpose?
To maintain sterile urine
What anti-microbial agents are most commonly used to treat VUR (2)? What is the dosage?
Trimethroprim
Sulfamethoxazole
1 daily dose at bedtime (1/2 or 1/4 of usual therapeutic dose)
Why must we not only treat the bladder but also bowel dysfunction when treating VUR?
Dysfunctional elimination syndrome (DES) may prolong time for VUR to resolve and lead to infections.
Explain how stooling and voiding function are related?
When you are constipated, the stool impinges on the bladder. This can prevent some parts of the bladder to void completely (creates risk of infection).
What is the purpose of a voiding/drinking diary? How does one keep a voiding diary? Same for bowel diary?
Voiding and drinking diary:
* objective documentation of voiding patterns
* records time, volume of urine, all fluids ingested, inconsistent episodes
* largest volume recorded represents the functional bladder capacity
Bowel diary:
* Records frequency and consistency of stool
How do we assess bowel dysfunction?
Bristol stool scale (images of different normal and abnormal stools to help children identify the type of stool they have).
If a child is hypertensive, they may have…
kidney disease
Name some signs of spinal cord defect (when to suspect) (5)
- Lipomeningocele (sac-like protrusion of spinal cord under skin of lower back)
- Vascular malformation (hyperpigmentation on lower back)
- Hair patch (lower back)
- Sacral dimple (lower back)
- Abnormal gluteal cleft (butt crack)
What are labial adhesions (in girls)?
Labial adhesions occur when the inner folds of the skin of the the vulva stick together (seen in young girls).
Symptoms & manifestations of labial adhesions (3)
Usually asymptomatic, but can cause:
* difficulty with urination
* recurrent urinary tract infections
* vaginitis
Labial adhesions treatment
Topical estrogen cream (if urination is affected)
Laboratory investigations for voiding dysfunction: What are the 3 main investigations? What do we look for?
A. Urinalysis & Microscopy:
* Screen for UTI (WBCs or nitrites in urine)
* Screen for diabetes (glucose in urine)
* Screen for urine concentrating defect (specific gravity)
B. Urine Culture & Sensitivity
* To rule out UTI
C. Bloodwork: Serum Electrolytes, Blood Gas & BUN/Creatinine
* Only in severe cases (especially if renal defect is suspected)
Radiologic investigations for voiding dysfunction (4)
- Lumbo-sacral spine films (x-ray)
- Plain abdominal films (x-ray)
- Ultrasonography (ultrasound)
- Voiding cystourethogram
Name the purpose of each of the following radiographic investigations (for voiding dysfunction):
1. Lumbo-Sacral Film
2. Plain Abdominal Film
3. Ultrasonography
4. Voiding Cystoureterogram
- Lumbo-Sacral Film: Assess spinal cord defects
- Plain Abdominal Film: Assess constipation
- Ultrasonography: Assess UTI or suspected structural anomalies and neurogenic dysfunction
- Voiding Cystourethrogram: Assess suspected vesico-ureteric reflux or posterior urethral valves
Voiding cystourethrogram
Bladder is filled with contrast and a catheter is inserted to obtain an x-ray or US image
When do we refer to urology/neurosurgery (bladder dysfunction in children)? (4)
- Genital exam is abnormal
- Lumbosacral spine is exam abnormal
- Neurological exam abnormal
- Total urinary incontinence
Children with high scores for voiding dysfunction on Dysfunction Elimination Syndrome questionnaire may benefit from… (3)
- Timed voiding schedule (void every 2-3 hours)
- Double voiding (urinating again right after voiding, within 2 min)
- Pelvic floor muscle training/anticholinergic drugs
How do we treat abnormal stools (corn-on-cob, grapes, rabbit droppings)?
- Increase dietary fibre
- Laxatives (3 months): Lactulose or polyethylene glycol (laxaday)
